Operative findings: (1) Dense adhesions in 14% patients (2) Fasteners incorporating the lateral crus in 95% (3) Good residual anterior plication in 75%, although frequently free fasteners were observed medially. (4) Good residual posterior plication in 0%. (5) Traction diverticuli from esophagus to crura in 21%. (6) The anterior-posterior dimension of the hiatus was > 3cm in 90% of patients.

Operative approaches: (1) Areas where the fundus was fused to the esophagus were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of intessusception. (2) Fasteners with one end free were left in-situ. (3) Fasteners between the lumen and another structure (e.g. esophagus and crura) were gently displayed, then cut and left to migrate into the lumen. (4) Seven patients with hiatal hernias underwent circumferential, level 1 mediastinal dissection and hiatal repair (5) In 8 patients with good intra-abdominal esophageal length, no significant hernia, and fusion of the lateral crus to TIF fundoplication, revision laparoscopic fundoplication was performed without mediastinal mobilization and the fused crura/fundoplication was left intact. (5) Traction diverticuli were divided, the fastener left in the esophageal lumen, and then oversewn.

Conclusion:
Failure after TIF fundoplication leading to reoperation is associated with a hiatus > 3cm and complete loss of the posterior portion of the fundoplication. The anterior portion of the fundoplication and lateral crural fixation generally remain intact. Meticulous attention to technical detail obviates the perforation risk from the transmural fasteners. Laparoscopic revision anti-reflux surgery for failed TIF is feasible and safe.